A safe and effective management strategy for blunt cerebrovascular injury: Avoiding unnecessary anticoagulation and eliminating stroke.

Introduction: Few injuries have produced as much debate with respect to management as have blunt cerebrovascular injuries (BCVI). Recent work (AAST 2013) from our institution suggested that 64-channel multi-detector computed tomographic angiography (CTA) could be the primary screening tool for BCVI. Consequently, our screening algorithm changed from digital subtraction angiography (DSA) to CTA, with DSA reserved for definitive diagnosis of BCVI following CTA positive studies or unexplained neurologic findings. The current study was done to evaluate outcomes, including the potential for missed clinically significant BCVI, since adopting this new management algorithm. Methods: Patients who underwent DSA (positive CTA or unexplained neurological finding) over an 18-month period subsequent to the previous study (PS) were identified. Screening and confirmatory test results, complications, and BCVI-related strokes were reviewed and compared. Results: 228 patients underwent DSA: 64% were male with mean age and Injury Severity Score of 43 and 22, respectively. 189 (83%) patients had a positive screening CTA. Of these, DSA confirmed injury in 104 (55%) patients; the remaining 85 (45%) patients (false positives) were found to have no injury on DSA. Five patients (4.8%) suffered BCVI-related strokes, unchanged from the PS (3.9%, p=0.756) - two were symptomatic at trauma center presentation, three occurred while receiving appropriate therapy. No patient with a negative screening CTA suffered a stroke. Conclusions: This management scheme utilizing 64-channel CTA for screening coupled with DSA for definitive diagnosis was proven to be safe and effective in identifying clinically significant BCVI and maintaining a low stroke rate. Definitive diagnosis by DSA led to avoidance of potentially harmful anticoagulation in 45% of CTA positive patients (false positives). No strokes resulted from injuries missed by CTA. Level of Evidence: Diagnostic Study, Level III (C) 2016 Lippincott Williams & Wilkins, Inc.

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